How America Lost the War on Drugs

Rolling Stone has a terrific article chronicling the failures of American drug policy over the last 14 years. Here's one lost opportunity:

"At the beginning of the Clinton administration," Cañas tells me, "the War on Drugs was like the War on Terror is now." It was, he means, an orienting fight, the next in a sequence of abstract, generational struggles that the country launched itself into after finding no one willing to actually square up and face it on a battlefield. After the Cold War, in the flush and optimism of victory, it felt to drug warriors and the American public that abstractions could be beaten. "It was really a pivot point," recalls Rand Beers, who served on the National Security Council for four different presidents. "We started to look carefully at our drug policies and ask if everything we were doing really made sense." The man Clinton appointed to manage this new era was Lee Brown.

Brown had been a cop for almost thirty years when Clinton tapped him to be the nation's drug czar in 1993. He had started out working narcotics in San Jose, California, just as the Sixties began to swell, and ended up leading the New York Police Department when the city was the symbolic center of the crack epidemic, with kids being killed by stray bullets that barreled through locked doors. A big, shy man in his fifties, Brown had made his reputation with a simple insight: Cops can't do much without the trust of people in their communities, who are needed to turn in offenders and serve as witnesses at trial. Being a good cop meant understanding the everyday act of police work not as chasing crooks but as meeting people and making allies.

"When I worked as an undercover narcotics officer, I was living the life of an addict so I could make buys and make busts of the dealers," Brown tells me. "When you're in that position, you see very quickly that you can't arrest your way out of this. You see the cycle over and over again of people using drugs, getting into trouble, going to prison, getting out and getting into drugs again. At some point I stepped back and asked myself, 'What impact is all of this having on the drug problem? There has to be a better way.' "

In the aftermath of the Rodney King beating, this philosophy - known as community policing - had made Brown a national phenomenon. The Clinton administration asked him to take the drug-czar post, and though Brown was skeptical, he agreed on the condition that the White House make it a Cabinet-level position. Brown stacked his small office with liberals who had spent the long Democratic exile doing drug-policy work for Congress and swearing they would improve things when they retook power. "There were basic assumptions that Republicans had been making for fifteen years that had never been challenged," says Carol Bergman, a congressional staffer who became Brown's legislative liaison. "The way Lee Brown looked at it, the drug war was focused on locking kids up for increasing amounts of time, and there wasn't enough emphasis on treatment. He really wanted to take a different tactic."

Brown's staff became intrigued by a new study on drug policy from the RAND Corp., the Strangelove-esque think tank that during the Cold War had employed mathematicians to crank out analyses for the Pentagon. Like Lockheed Martin, the jet manufacturer that had turned to managing welfare reform after the Cold War ended, RAND was scouting for other government projects that might need its brains. It found the drug war. The think tank assigned Susan Everingham, a young expert in mathematical modeling, to help run the group's signature project: dividing up the federal government's annual drug budget of $13 billion into its component parts and deciding what worked and what didn't when it came to fighting cocaine.

Everingham and her team sorted the drug war into two categories. There were supply-side programs, like the radar and ships in the Caribbean and the efforts to arrest traffickers in Colombia and Mexico, which were designed to make it more expensive for traffickers to bring their product to market. There were also demand-side programs, like drug treatment, which were designed to reduce the market for drugs in the United States. To evaluate the cost-effectiveness of each approach, the mathematicians set up a series of formulas to calculate precisely how much additional money would have to be spent on supply programs and demand programs to reduce cocaine consumption by one percent nationwide.

"If you had asked me at the outset," Everingham says, "my guess would have been that the best use of taxpayer money was in the source countries in South America" - that it would be possible to stop cocaine before it reached the U.S. But what the study found surprised her. Overseas military efforts were the least effective way to decrease drug use, and imprisoning addicts was prohibitively expensive. The only cost-effective way to put a dent in the market, it turned out, was drug treatment. "It's not a magic bullet," says Reuter, the RAND scholar who helped supervise the study, "but it works." The study ultimately ushered RAND, this vaguely creepy Cold War relic, into a position as the permanent, pragmatic left wing of American drug policy, the most consistent force for innovating and reinventing our national conception of the War on Drugs.

When Everingham's team looked more closely at drug treatment, they found that thirteen percent of hardcore cocaine users who receive help substantially reduced their use or kicked the habit completely. They also found that a larger and larger portion of illegal drugs in the U.S. were being used by a comparatively small group of hardcore addicts. There was, the study concluded, a fundamental imbalance: The crack epidemic was basically a domestic problem, but we had been fighting it more aggressively overseas. "What we began to realize," says Jonathan Caulkins, a professor at Carnegie Mellon University who studied drug policy for RAND, "was that even if you only get a percentage of this small group of heavy drug users to abstain forever, it's still a really great deal."

Thirteen years later, the study remains the gold standard on drug policy. "It's still the consensus recommendation supplied by the scholarship," says Reuter. "Yet as well as it's stood up, it's never really been tried."

To Brown, RAND's conclusions seemed exactly right. "I saw how little we were doing to help addicts, and I thought, 'This is crazy,' " he recalls. " 'This is how we should be breaking the cycle of addiction and crime, and we're just doing nothing.' "

The federal budget that Brown's office submitted in 1994 remains a kind of fetish object for certain liberals in the field, the moment when their own ideas came close to making it into law. The budget sought to cut overseas interdiction, beef up community policing, funnel low-level drug criminals into treatment programs instead of prison, and devote $355 million to treating hardcore addicts, the drug users responsible for much of the illegal-drug market and most of the crime associated with it. White House political handlers, wary of appearing soft on crime, were skeptical of even this limited commitment, but Brown persuaded the president to offer his support, and the plan stayed.

Still, the politics of the issue were difficult. Convincing Congress to dramatically alter the direction of America's drug war required a brilliant sales job. "And Lee Brown," says Bergman, his former legislative liaison, "was not an effective salesman." With a kind of loving earnestness, the drug czar arranged tours of treatment centers for congressmen to show them the kinds of programs whose funding his bill would increase. Few legislators came. Most politicians were skeptical about such a radical departure from the mainstream consensus on crime. Congress rewrote the budget, slashing the $355 million for treatment programs by more than eighty percent. "There were too many of us who had a strong law-and-order focus," says Sen. Chuck Grassley, a Republican who ­opposed the reform bill and serves as co-chair of the Senate's drug-policy caucus.

For some veteran drug warriors, Brown's tenure as drug czar still lingers as the last moment when federal drug policy really made sense. "Lee Brown came the closest of anyone to really getting it," says Carnevale, the longtime budget director of the drug-control office. "But the bottom line was, the drug issue and Lee Brown were largely ignored by the Clinton administration." When Brown tried to repeat his treatment-centered initiative in 1995, it was poorly timed: Newt Gingrich and the Republicans had seized control of the House after portraying Clinton as soft on crime. The authority to oversee the War on Drugs passed from Rep. John Conyers, the Detroit liberal, to a retired wrestling coach from Illinois who was tired of drugs in the schools – a rising Republican star named Dennis Hastert. Reeling from the defeat at the polls, Clinton decided to give up on drug reform and get tough on crime. "The feeling was that the drug czar's office was one of the weak areas when it came to the administration's efforts to confront crime," recalls Leon Panetta, then Clinton's chief of staff.

What I find encouraging is that I see no reason to believe the window of opportunity for that 1995 plan was permanently closed. In fact, it seems that it may be opening again right now. There seems to be a growing bipartisan consensus that the drug war's emphasis on incarceration has been a disaster. It seems to me that the only reason we haven't changed course is that Washington doesn't see a politically viable alternative. Public interest in relatively low, I suspect that this is because the public also doesn't see any good options. The time may be right for a sensible alternative to emerge from the din of the legalization and tough on crime crowds. Obama and Huckabee have laid some groundwork but other candidates are more wary.

The Peace Drug (MDMA)

The Washington Post recently ran a story on a researcher looking at ecstasy as a treatment for PTSD:

THE CAPSULES RESIDE IN A SAFE, armed with an alarm and bolted to the floor of Mithoefer's office, a 1950s-vintage cottage on the road between downtown Charleston and Sullivans Island. It's been tastefully remodeled to create a softly lit, high-ceilinged sanctuary in the back, scattered with art and furnished with, among other things, the ever-so-slightly inclined futon where Donna got crooked.

The elaborate security is occasioned by what is inside the capsules: MDMA, a synthetic compound that is a chemical cousin to both mescaline and methamphetamine. Unabbreviated, MDMA is a real mouthful -- 3,4-methylenedioxymethamphetamine -- but it is far better known by its street name, ecstasy, millions of doses of which are synthesized in criminal labs from the oil of the sassafras plant. At one point, Mithoefer recounts, agents of the Drug Enforcement Administration, there to inspect the security arrangements, inquired about the therapist who rents the office adjoining the safe room.

"I guess they were concerned she might drill through the wall into the safe and steal the MDMA," Mithoefer says. "Though there's such a small amount in there, and it's so readily available on the street in such large quantities, I don't see how that would be worth the effort, even if she were so inclined."

Mithoefer became a psychiatrist in 1991, after a decade as an emergency room doctor -- he had found himself less interested in the bodily traumas his patients suffered than the psychological traumas that so often preceded their appearance in the emergency room. He's got that mellow, empathic vibe that they just can't teach at therapy school. He always seems moments away from a sympathetic chuckle, an understanding murmur or a sage observation. A fit 61, with a brown ponytail and relaxed dress code, Mithoefer has become the accidental point man of a movement to revive medical research into psychedelic drugs. His Food and Drug Administration-approved PTSD study that began with Donna Kilgore in April 2004 is now nearly completed, with 18 of 21 subjects having undergone the double-blind sessions. Two Iraq veterans with war-related PTSD, the study's first, are cleared to begin. Close behind are similar studies in Switzerland and Israel. At Harvard's McLean Hospital, researchers are set to evaluate MDMA therapy as a way to alleviate acute anxiety in terminal cancer patients. In Vancouver, Canada, the effectiveness of an ongoing program to treat drug addiction with another potent psychedelic drug, ibogaine, is under scrutiny. There is a proposal, based on case histories, to study the ability of LSD to defuse crippling cluster headaches.

All of these studies are directly or indirectly funded by a surprisingly robust organization whose roots stretch back 40 years to the psychedelic movement of the 1960s. Before Harvard lecturer Timothy Leary started channeling aliens and urging college kids to turn on and drop out, an intense cadre of doctors and researchers had come to believe that psychedelic drugs would revolutionize psychiatry, providing those with a wide spectrum of psychological problems -- or even just ordinary life difficulties -- the ability to, basically, heal themselves.

But Leary's bizarre career, which morphed from doing research on psychedelics to cheerleading their widespread abuse, obscured whatever medical potential the drugs may have had. Instead, authorities focused on the risks, and often exaggerated them. Richard Nixon famously called Leary "the most dangerous man in America." After a slow start, regulators and legislators cracked down hard. Millions of dollars in enforcement efforts were unable to end abuse of psychedelic drugs, but they effectively stamped out sanctioned research into their healing potential.

A small group of psychedelic researchers and therapists willing to break the law continued their work clandestinely. A much larger group did not flout the law, but waited in the wings and is now emerging. Experience had convinced these therapists that psychedelics, along with significant risks, had potential for even more significant benefits.

This may have been especially true of MDMA.

Mithoefer states the case in an article he wrote for a book of scholarly essays, Psychedelic Medicine: Social, Clinical and Legal Perspectives:"The reported results [of early therapeutic use] include decreased fear and anxiety, increased openness, trust and interpersonal closeness, improved therapeutic alliance, enhanced recall of past events with an accompanying ability to examine them with new insight, calm objectivity and compassionate self-acceptance."

In short, a therapist's dream. Or is it a hallucination?

THE PROMISE OF A BLOCKBUSTER TREATMENT, one that doesn't just address symptoms but defuses underlying causes, is a particularly seductive vision right now. A report issued last month by the National Academy of Sciences' Institute of Medicine emphasizes the uncertain effectiveness of current PTSD treatments, and the urgent need of returning soldiers who will suffer from it.

To a non-scientist, the very preliminary results of Mithoefer's study would suggest that MDMA might be just what the doctors ordered. Of the subjects who have been through both the MDMA-assisted therapy and the three-month post-experiment follow-up tests, Mithoefer reports, every one showed dramatic improvement.

But scientists are a cautious lot. "It's potentially nice to hear those things," says Scott Lilienfeld, an associate professor of psychology at Emory University. But until results are statistically analyzed and peer-reviewed for publication, "you can't really judge them. The plural of anecdote is not data." Especially with a drug that has considerable risk, Lilienfeld cautions, it pays to be skeptical.

A.C. Parrott, a psychologist at Swansea University in Britain who has devoted a large part of his career to studying the dangers of MDMA, is far more than skeptical. "MDMA is a very powerful, neurochemically messy and potentially damaging drug," he says. The government "should never have given it a license for these trials. Certainly I would not give it a license for any further trials."

But one of the nation's premier PTSD researchers, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, disagrees. Morphine is a powerful, potentially damaging drug, Pitman says, "and we use it to treat the pain of cancer patients. Sound medical reasons should trump."

Current treatment for PTSD is "partial at best," he says. "There's a lot of room for improvement, and we need to be looking for novel treatments."

Though Pitman calls the MDMA study "a fringe hypothesis" -- "I've never heard anybody talk about it at any PTSD meeting I've ever attended in 25 years" -- he also observes that, based solely on a description of the preliminary results, "this seems worth further study. A lot of new ideas meet with rejection and skepticism, and we need to be careful not to be prejudiced against something just because it seems wacky. If it has a 5 percent chance, or even a 1 percent chance, of being effective in treatment of PTSD, it's worth pursuing."

This isn't new, I posted about this back in January.

[hat tip: Don Phillips]

Club drugs inflict damage similar to traumatic brain injury

I read headlines like this on and roll my eyes that it is an ONDCP hype job. However, Mark Gold has a good reputation.

University of Florida researchers say both may trigger a similar chemical chain reaction in the brain, leading to cell death, memory loss and potentially irreversible brain damage.

A series of studies at UF over the past five years has shown using the popular club drug Ecstasy, also called MDMA, and other forms of methamphetamine lead to the same type of brain changes, cell loss and protein fluctuations in the brain that occur after a person endures a sharp blow to the head, according to findings a UF researcher presented at a Society for Neuroscience conference held in San Diego this month.

“Using methamphetamine is like inflicting a traumatic brain injury on yourself,” said Firas Kobeissy, a postdoctoral associate in the College of Medicine department of psychiatry. “We found that a lot of brain cells are being injured by these drugs. That’s alarming to society now. People don’t seem to take club drugs as seriously as drugs such as heroin or cocaine.”

Working with UF researchers Dr. Mark Gold, chief of the division of addiction medicine at UF’s McKnight Brain Institute and one of the country’s leading experts on addiction medicine, and Kevin Wang, director of the UF Center for Neuroproteomics and Biomarkers Research, Kobeissy compared what happened in the brains of rats given large doses of methamphetamine with what happened to those that had suffered a traumatic brain injury.

The group’s research has already shown how traumatic brain injury affects brain cells in rats. They found similar damage in the rats exposed to methamphetamine. In the brain, club drugs set off a chain of events that injures brain cells. The drugs seem to damage certain proteins in the brain, which causes protein levels to fluctuate. When proteins are damaged, brain cells could die. In addition, as some proteins change under the influence of methamphetamine, they also begin to cause inflammation in the brain, which can be deadly, Kobeissy said.

Kobeissy and other researchers in Gold’s lab are using novel protein analysis methods to understand how drug abuse alters the brain. Looking specifically at proteins in the rat cortex, UF researchers discovered that about 12 percent of the proteins in this region of the brain showed the same kinds of changes after either methamphetamine use or traumatic brain injury. There are about 30,000 proteins in the brain so such a significant parallel indicates that a similar mechanism is at work after both traumatic brain injury and methamphetamine abuse, Kobeissy said.

Alcohol sales and violence

A while back, England wrestled with how to reduce violence after closing hours for the pubs and decided to allow 24 hour alcohol sales. Early returns were positive, the second wave of reports look negative.

Brazil is a different country with a different culture, but the results of this study don't look too promising:

Objective. We investigated whether limiting the hours of alcoholic beverage sales in bars had an effect on homicides and violence against women in the Brazilian city of Diadema. The policy to restrict alcohol sales was introduced in July 2002 and prohibited on-premises alcohol sales after 11 PM.

Methods. We analyzed data on homicides (1995 to 2005) and violence against women (2000 to 2005) from the Diadema (population 360 000) police archives using log-linear regression analyses.

Results. The new restriction on drinking hours led to a decrease of almost 9 murders a month. Assaults against women also decreased, but this effect was not significant in models in which we controlled for underlying trends.

Conclusions. Introducing restrictions on opening hours resulted in a significant decrease in murders, which confirmed what we know from the literature: restricting access to alcohol can reduce alcohol-related problems. Our results give no support to the converse view, that increasing availability will somehow reduce problems.

The Addiction Wars

Time science writer Michael Lemonick blogs an exchange with a commenter who resists the suggestion that addiction will eventually be treated with a pill.

Abortion linked to drugs, alcohol abuse

Another harm associated with drug addiction:

Young women who have abortions are more likely to drink heavily and abuse hard drugs, an Australian study has found.

...

The study tracked 1,122 young women who were born at the Mater hospital in the early 1980s, finding that 21 years on, about one-third had an abortion.

Those who had an abortion were three times more likely to also abuse hard drugs, like heroin, methamphetamines and glue, than the women who had either had no pregnancy or those who had a child.

They were also twice as likely to be a binge drinker or an alcoholic, and 1.5 times more likely to suffer depression, delegates at the World Psychiatric Association (WPA) conference in Melbourne were told.

Sleepiness drug 'helps ice addicts'

Back to the future! A stimulant to treat stimulant addiction.

Next they'll be researching the effectiveness of benzos for treating alcoholism.

Tale of Three Medics

ABC News has a story on soldiers developing drug and alcohol problems as they return to the U.S. The story will also air on 20/20 this Friday night.

Youth addictions are up, study finds

What I find shocking is not the increase, but how grossly undertreated addiction has been among young people in Detroit. 42?

The number of young Detroiters treated for substance-abuse addictions -- from alcohol to marijuana to crack cocaine and heroin -- increased sharply in the past three years, according to a public health study released Tuesday.

In 2003, 42 people ages 12 to 18 were treated. A year later, the number rose to 179. Last year it was 377.

New parity estimate

A new Congressional Budget Office estimate of the costs associated with Paul Wellstone Mental Health and Addiction Equity Act of 2007:

We estimate that the direct costs of the additional services that would be newly covered by insurance because of the mandate would equal about 0.4 percent of employer-sponsored health insurance premiums compared to having no mandate at all.

Irish priests fear driving bans over altar wine

Clergy, Eucharist and OUIL:

Celebrating more than one mass a day may push Roman Catholic priests over the alcohol limit if tougher drink driving rules come into effect in Ireland, a leading clergyman said on Friday.

Altar wine is an essential part of the eucharist, the ritual in which Catholics believe the priest turns bread and wine into the body and blood of Jesus Christ. A priest drinks a small amount of the wine during the mass.

Under proposed Irish legislation, the limit of 80 milligrams of alcohol per 100 millilitres of blood is expected to be tightened but no new level has yet been specified.

Because the ranks of the Catholic clergy are thinning out, priests -- especially in rural areas -- often drive to several churches on Sunday to say mass for congregations who have no resident clergy.

"You could be over the limit trying to travel between maybe two or three churches on a Sunday morning and coming back again," Father Brian D'Arcy told Reuters.

D'Arcy is a broadcaster and rector of the Passionist Monastery in Enniskillen, Northern Ireland, where similar changes have also been proposed.

He said wine prepared for use in services had to be consumed and throwing it away was blasphemous.

Dr. Drug Rep

A psychiatrist writes about the influence of drug company money on his judgment and integrity.

Relapse Among Individuals in Remission From Alcohol Dependence

From Alcoholism: Clinical and Experimental Research

Background: There is little information on the stability of abstinent and nonabstinent remission from alcohol dependence in the general U.S. population. The aim of this study was to examine longitudinal changes in recovery status among individuals in remission from DSM-IV alcohol dependence, including rates and correlates of relapse, over a 3-year period.

Methods: This analysis is based on data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. adults aged 18 years and older originally interviewed in 2001 to 2002 and reinterviewed in 2004 to 2005. The Wave 1 NESARC identified 2,109 individuals who met the DSM-IV criteria for full remission from alcohol dependence. Of these, 1,772 were reinterviewed at Wave 2, comprising the analytic sample for this study. Recovery status at Wave 2 was examined as a function of type of remission at Wave 1, with a focus on rates of relapse, alternately defined as recurrence of any alcohol use disorder (AUD) symptoms and recurrence of DSM-IV alcohol dependence. Logistic regression models were used to estimate the odds of relapse among asymptomatic risk drinkers and low-risk drinkers relative to abstainers, adjusted for a wide range of potential confounders.

Results: By Wave 2, 51.0% of the Wave 1 asymptomatic risk drinkers had experienced the recurrence of AUD symptoms, compared with 27.2% of low-risk drinkers and 7.3% of abstainers. Across all ages combined, the adjusted odds of recurrence of AUD symptoms relative to abstainers were 14.6 times as great for asymptomatic risk drinkers and 5.8 times as great for low-risk drinkers. The proportions of individuals who had experienced the recurrence of dependence were 10.2, 4.0, and 2.9%, respectively, and the adjusted odds ratios relative to abstainers were 7.0 for asymptomatic risk drinkers and 3.0 for low-risk drinkers. Age significantly modified the association between type of remission and relapse. Differences by type of remission were not significant for younger alcoholics, who had the highest rates of relapse.

Conclusions: Abstinence represents the most stable form of remission for most recovering alcoholics. Study findings highlight the need for better approaches to maintaining recovery among young adults in remission from alcohol dependence, who are at particularly high risk of relapse.

[via: Alcohol Reports]

European Drug Trends

Cocaine and meth appear to be hitting Europe. It will be interesting to watch the impact of these trends on their drug policies.

It’s not either/or, it’s both/and.

From Barack Obama:

When I’m president, we will no longer accept the false choice between being tough on crime and vigilant in our pursuit of justice. Dr. King said: “It’s not either/or, it’s both/and.” We can have a crime policy that’s both tough and smart. If you’re convicted of a crime involving drugs, of course you should be punished. But let’s not make the punishment for crack cocaine that much more severe than the punishment for powder cocaine when the real difference between the two is the skin color of the people using them. Judges think that’s wrong. Republicans think that’s wrong, Democrats think that’s wrong, and yet it’s been approved by Republican and Democratic presidents because no one has been willing to brave the politics and make it right. That will end when I am president.

Medical Marijuana

Medical marijuana will be on the ballot in Michigan.

Chantix concerns

The FDA has issued an Early Communication About an Ongoing Safety Review
Varenicline (marketed as Chantix).

I don't recall - I must have slept well

The New York Times Magazine ran a story on the sleep industrial complex. Of course, a big segment of that are medications:

...In one six-week trial, for example, people taking Ambien every night fell asleep, on average, only 23 minutes faster than those taking the placebo. They spent 88 percent of their time in bed asleep, as opposed to 82 percent. Given that their objectively measured improvements are frequently this meager, why do sleeping pills create incommensurate feelings of having slept so well?

A popular theory is that one of the pill’s side-effects is actually contributing to their success. Most sleeping pills are known to block the formation of memories during their use, creating amnesia. This is why people who endure freaky side-effects — so-called “complex sleep-related behaviors” like getting into a car and driving or ravenously eating, all while asleep — don’t remember those events. Yet this amnesia could be quite beneficial, suggests Michael Bonnet, a professor of neurology at Wright State University Boonshoft School of Medicine in Dayton, Ohio. “How do you know you slept last night?” Bonnet asked me. A night of lousy, interrupted sleep, he points out, is easy to remember. “It’s full of memories, noise and pain, and heat and rolling around and obtrusive thoughts and worries — all of these various stimuli.” And we may continue to register such things even while asleep, making sleep vaguely unrefreshing. But a good night of sleep, Bonnet went on to say, “is always the antithesis to all those things, which is oblivion.” A sleeping pill, Bonnet speculates, in addition to encouraging sleep chemically in the brain, also “erases all of these thoughts that we use to define ourselves as being awake. The pill knocks them all out, and the patient says, ‘Hey, I must have been asleep because I don’t remember anything.’ ”

Drug-company representatives and consultants I spoke to confirm that their pills can create this mild form of amnesia but disagree that it contributes any significant benefit. “That is not my understanding of how Ambien works,” Dario Mirski, a psychiatrist and spokesman for Ambien’s manufacturer, Sanofi-Aventis, told me. It is difficult to find a clinical trial in which Z-drug takers drastically overestimated how long they slept.

Andrew Krystal, a Duke University psychiatrist and consultant to pharmaceutical companies like Sepracor, Lunesta’s manufacturer, acknowledges an apparent discrepancy in studies between small, objectively recorded improvements and the large percentage of subjects who end up feeling that a pill alleviated their insomnia. But because insomnia is complaint-based, he explained to me, an insomniac is cured when he stops complaining.

Interestingly, studies looking at sleep disturbance in alcoholics and relapse have found that sleep disturbance is not a great predictor of relapse, but distress over sleep disturbance is a predictor. What does that suggest?

Prohibition

From a friend of a friend:

I am presently reading the book, “Paying the Tab: The Costs and Benefits of Alcohol Control,” by Philip J. Cook, Professor for Public Policy at Duke University. The book, just published by Princeton University Press, is excellent. It examines in detail the problem of alcohol consumption and abuse in the United States from the colonial era to the present. It is even handed, beautifully and clearly written, even in the presentation of knotty statistical data, meticulously researched, and heftily footnoted (25 pages of references.) It is simply the best overview of alcohol abuse I have ever read.

It punctures some myths and some favorite ideas:

EVERYONE KNOWS THAT PROHIBITION DIDN’T WORK
Prohibition was a failure in the sense that it lost popular support, but it was associated with a sharp reduction in alcohol consumption, alcoholism, incidences of domestic abuse due to alcohol, drunken driving, and especially cirrhosis of the liver (which fell by 50%). These facts are indisputably documented in the book.

DISTILLERS WOULD BE OH SO HAPPY IF EVERYONE “DRANK RESPONSIBLY.”
If that happened, they would go out of business. 80% of alcohol is consumed by 20% of the drinking population. Most alcohol is consumed by alcohol abusers. This 80/20 rule, which holds for other consumer products as well, was discovered in France, and seems to hold for alcohol consumption in all countries.

A LARGE PROPORTION OF THE AVERAGE HOUSEHOLD INCOME IS SPENT ON ALCOHOL
Alcohol sales in the US for the year 2001 amount to 128 billion dollars. That amounts to less than 2% of personal consumption expenditures that year.

EVERYONE DRINKS
We hear this from AA newcomers, and it is completely false. Over 50% of the population in the US consume so little alcohol (less than one drink per month at the most) that they may be called nondrinkers. 35% of the US population did not have even a single drink of alcohol in 2000! Again, this fact is convincingly documented.

ALCOHOL ABUSE IS MOST PREVALENT IN LOWER INCOME AND UNDEREDUCATED FAMILIES
Most alcohol is consumed by families earning $80 000 a year or more. Most is consumed by those with some college education. Black Americans consume much much less alcohol than Hispanics (50% less) who drink less than Caucasians.

GET HIM OR HER INTO THE RIGHT PROGRAM, AND THE DRINKING PROBLEM IS SOLVED
The author discusses the many different treatment modalities for alcohol abusers, and is very bullish on AA. However, for most alcohol abusers, nothing seems to work. If you are sober in AA, you should be effusive in your gratitude.

MOST ALCOHOL PROBLEMS ARE CAUSED BY ALCOHOLICS
This, strangely, does not seem to be true. To quote the author: “The reason is the ‘preventive paradox’ ---- while problems are concentrated among long-time heavy drinkers who are in enough trouble that they might be persuaded (or coerced) into seeking treatment, the bulk of alcohol related problems are diffused among the much larger group.”

GOVERNMENT EFFORTS TO CONTROL CONSUMPTION WILL INEVITABLY FAIL
The clear conclusion is that even modest government efforts to limit supply can reduce alcohol consumption. Prohibition drastically limited consumption in the lower classes (while not making a dent in the drinking habits of the affluent, who felt entitled.)

What is the author’s personal investment in this issue? Well, he holds his cards close to his vest (as he should, this being a scholarly study) but his dropping occasionally adages like, “Denial is not a river in Egypt,” will cause the cognoscenti to nod.

Settling into harm reduction

Here's an appeal for a shift toward abstinence in the U.K. It describes what's happened to recovery in a system focused on harm reduction.

via www.dailydose.net

Treatment for internet addiction!

Jump Up Internet Rescue School

5 Armies Hopped Up on Drugs

I've read about the other four, but I don't know what to think about number five. Hash is not the drug I'd give someone I was sending off to war.

A Hidden Epidemic

The Washington Post has a great op-ed on smoking among people with mental illness:

Virtually everyone knows about the connection between smoking and health. Smoking causes 440,000 deaths a year in the United States (50,000 of which are from exposure to secondhand smoke) and 5 million worldwide. It shortens smokers' lives by 10 to 15 years, and those last few years can be a miserable combination of severe breathlessness and pain.

But few are aware that smoking is concentrated among people with mental illness, often compounded by substance-abuse disorders such as alcoholism. Go to most Alcoholics Anonymous meetings, and the room will be so full of smoke that you can cut it with a knife. Ask the members, and they will tell you that it was much easier to stop drinking than to stop smoking. Indeed, nicotine, the addictive component of tobacco smoke, is as habituating as cocaine or heroin, and it has a similar effect on chemical receptors in the brain.

The facts about smoking and mental illness are stark. Almost half of all cigarettes sold in the United States (44 percent) are consumed by people with mental illness. (emphasis added) This is because so many people who have mental illnesses smoke (50 to 80 percent, compared with less than 20 percent of the general population) and because they smoke so many cigarettes a day -- often three packs. Furthermore, smokers with mental illness are much more likely to smoke their cigarettes right down to the filters.

His comments about AA wouldn't be accurate around here. Certainly, smoking rates among AA members are very high, but I think most meetings are non-smoking. I haven't been to a smoking meeting in close to 10 years.

New York to ban smoking in treatment centers

Good for New York, but I thought New Jersey did this. If you know something I don't, tell me in comments:

For decades, addiction-treatment programs have honed in on drug and alcohol abuse and shrugged at patients' near-universal use of tobacco.

But faced with growing awareness about the power of nicotine addiction and that smoking kills more people than all other addictive drugs combined, New York officials have decided the state can no longer afford to ignore smoking.

"The entire field has struggled with the really incorrect notion that treating nicotine addiction would be really a hardship on the chemically addicted," said Karen Carpenter-Palumbo, commissioner of the state Office of Alcoholism and Substance Abuse Services.

In July, New York will become the first state in the nation to ban smoking at all its chemical dependence prevention and treatment programs, including those that treat gambling addiction.

In Florida, Addicts Find an Oasis of Sobriety

The New York Times recently printed an article about Delray Beach, Florida, and its high concentration of recovering alcoholics. They make it sound weird by seeking comments from gadfly Stanton Peele. I suppose it could be a little weird, but isn't it a nearly universal instinct to surround oneself with people with similar identities? Is the high concentration of LGBT people in Ferndale a sign of pathology?

I've never been there, but I'm pretty confident that Peele is engaging in his usual hyperbole and misrepresentation with his statement about these people "cutting [themselves] off from the outside world." Many of these people were probably cut off from the outside world in their addiction and are rejoining the rest of the world with the support of a community and environment that affirms and celebrates their recovery.

Drugs, Alcohol and Homelessness

From a new Gallup poll:

More than eight in 10 people surveyed believe abuse of alcohol and drugs is the major cause of homelessness.

The public gets it. Now, what to do about it? In the context of the collapse of the American addiction treatment system, the intersection of homelessness and addiction stands out as the biggest challenge in addressing chronic, high severity severe addiction.

Dopamine and alcoholism

Time magazine's science writer simplifies a recent study on neurobiology and alcoholism:

It's already known that addictive drugs, including alcohol, trigger a rush of dopamine. Getting that literal rush is such a powerful reward that it's a big part of the reason addicts go back to drugs, even though they know objectively that it's a truly bad idea.

Now comes a paper in the Journal of Neuroscience that adds another key piece to the addiction puzzle. Nora Volkow, director of the National Institute on Drug Abuse, long with several colleagues, used brain-imaging studies to look at the dopamine responses of alcoholics—not to alcohol, but to a different drug, methylphenidate, better known by its trade name Ritalin. In normal subjects, the drug causes a spike in dopamine in the brain's prefrontal cortex.

But in alcoholics, the study found, that spike is significantly muted. Says Volkow: "It could explain why alcoholics encounter a decrease in the ability to experience pleasure from everyday activities." In essence, they've been overstimulating their dopamine systems for so long with alcohol that their brains have become numb. It also explains why so many relapse into drinking; it's the one way they can experience any sort of pleasure.

House and Senate Agree on Addiction Budget; Veto Expected

From JoinTogether.org:

A House-Senate conference committee has approved a FY2008 budget plan that calls for spending $1.779 billion on the Substance Abuse Prevention and Treatment Block Grant and increasing the budgets of the Center for Substance Abuse Prevention (CSAP), Center for Substance Abuse Treatment (CSAT), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

President Bush is expected to veto the measure, however.

The block-grant funding represents a $20-million increase over the $1.759 million appropriated in FY2007, falling roughly between the figures approved by the House and Senate in their respective budget bills for the Departments of Labor, HHS, and Education. The National Association of State Alcohol and Drug Abuse Directors (NASADAD) reported that the committee bill did not include language tying funding to a set of National Outcome Measures -- which many in the field objected to.

...

The one big budget loser was the state grants portion of the Safe and Drug-Free Schools and Communities program, which conference negotiators decided to fund at $300 milllion, down from $346.5 million in 2007.

President Bush's veto threat stems from the fact that the budget plan is $9.8 billion more than his request, according to NASADAD. The Labor/HHS funding plan was combined in conference with the budgets for the Veterans' Affairs department and the Military Construction budget -- with supporters betting that Bush would be loathe to veto funding for veterans and the military -- but Senate Republicans succeeded in de-linking the funding measures in a floor vote this week, casting the fate of the Labor/HHS bill in further doubt.

Should drugs be decriminalised?

BMJ has published for and against commentaries on legalizing drugs. The introduction says a lot:

Recent government figures suggest that the UK drug treatment programmes have had limited success in rehabilitating drug users, leading to calls for decriminalisation from some parties.

Not suprising that they've had limited success--their efforts have been very limited, especially for drug-free treatment.

via dailydose.net

Panel May Cut Sentences For Crack

Long overdue:

An independent panel is considering reducing the sentences of inmates
incarcerated in federal prisons for crack cocaine offenses, which would make
thousands of people immediately eligible to be freed.

The U.S. Sentencing Commission, which sets guidelines for federal
prison sentences, established more lenient guidelines this spring for future
crack cocaine offenders. The panel is scheduled to consider today a proposal to
make the new guidelines retroactive.

Should the panel adopt the new policy, the sentences of 19,500 inmates
would be reduced by an average of 27 months. About 3,800 inmates now imprisoned
for possession and distribution of crack cocaine could be freed within the next
year, according to the commission's analysis. The proposal would cover only
inmates in federal prisons and not those in state correctional facilities, where
the vast majority of people convicted of drug offenses are held.

It also addresses the disparate racial impact of the law. Good read.

via dailydose.net

On the Bottle, Off the Streets, Halfway There

Another housing first program for chronic alcoholics:

Early last year, some people, not cops, tracked Daryl down at the sobering center, where he had slept off a drunk 360 times in one calendar year. They were from a homeless outreach organization and they had some news, good for a change.

The organization had just built a 75-unit residence for homeless chronic alcoholics at 1811 Eastlake Avenue, and was offering rooms to the frailest and costliest to the system, as determined by time spent in the sobering center, the emergency room and jail. The idea: provide them first with housing and meals, gain their trust, then encourage them to partake of the available services, including treatment for chemical dependency.

No mandatory meetings or church-going. And one more thing, crucial to all: You can drink in this place.

Welcome, Daryl. A month later: Welcome, Ed.

“I damn near bawled,” Ed recalls.

The $11 million project has endured the angry complaints of some that it uses public money to enable, even reward, chronic inebriates. And Bill Hobson, the director of the Downtown Emergency Service Center, has met that anger with some of his own.

First, he says, the complaints reflect no understanding of the grip of alcoholism: Do you really think these men and women would rather live on the streets? Second, the cost to the public appears to have dropped as the number of visits to the emergency room, jail and the sobering center has plummeted.

Finally, he asks, what kind of equation of humanity is this: Since you refuse to stop drinking, since you refuse to address your disease, you must die on the streets.

“These guys have nothing going for them,” he says. “They could not be more dispossessed.”

Reasonable people can disagree on these matters, but these articles always seem to focus on what is not required of program participants, they never seem to focus on what it required or expected of service providers. Here's what I had to say earlier this year about a PBS segment on a homeless addict provided housing with no contingencies:

I had several reactions to the segment. First, had Footie ever been provided with comprehensive treatment of and adequate dosage, duration? Why no contingencies? Maybe his housing shouldn't be contingent upon abstinence, but how about participation in treatment? If the fear is that this might be a set-up, how about reviewing it at monthly or quarterly intervals so that a bad week does not put him back on the street? Why not at least make it recovery-focused? If this approach is good for Footie and raises his functioning and quality of life to his potential, who's functioning and quality of life might be reduced to something below their potential? At Dawn Farm, we see some clients who would probably benefit greatly from a recovery-focused housing program that is not contingent upon abstinence. However, how many of clients who are currently in full recovery would have settled into an apartment like Footie's and never achieved stable recovery and a full, satisfying life? Many, I think.

UPDATE: This isn't to say it shouldn't be done, but rather how to go about it in a way that doesn't lower the bar for all homeless addicts and fail to address what caused their homelessness. Maybe one way to approach it is to ask, "Absent their addiction, would this person still be likely to be homeless?" In the case of Footie, the answer is "probably so". In the case of most of our homeless clients, the answer is "unlikely".

Of course, another big question is how to prioritize services in the context of scarce resources.

The Physiology of Addiction by Dr. Carl Christensen

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sweets or cocaine?

I get the attraction to sweets, but not addicted rats choosing sugar over cocaine. The article suggests that it enhances understanding of attraction to sweets and obesity, but is there expected to be any value in understanding or treating drug addiction. If anyone can enlighten me, feel free to do so in comments.

Researchers have learned that rats overwhelmingly prefer water sweetened with saccharin to cocaine, a finding that demonstrates the addictive potential of sweets.

Offering larger doses of cocaine did not alter the rats' preference for saccharin, according to the report.

Scientists said the study, presented this week in San Diego at the annual meeting of the Society for Neuroscience, might help explain the rise in human obesity, which has been driven in part by an overconsumption of sugary foods.

In the experiment, 43 rats were placed in cages with two levers, one of which delivered an intravenous dose of cocaine and the other a sip of highly sweetened water. At the end of the 15-day trial, 40 of the rats consistently chose saccharin instead of cocaine.

When sugar water was substituted for the saccharin solution, the results were the same, researchers said.

Further testing the rat sweet tooth, scientists subjected 24 cocaine-addicted rats to a similar trial. At the end of 10 days, the majority of them preferred saccharin.

"Intense sweetness is more rewarding to the rats than cocaine," said coauthor Magalie Lenoir of the University of Bordeaux in France.

Lenoir said mammalian taste receptors evolved in an environment that lacked sugar and so were not adapted to the high concentrations of sweets found in the modern diet. Excess sugar could increase levels of the brain chemical dopamine, she said, leading to a craving for sweets.

Cocaine also increases dopamine, she said, but through a different brain mechanism.

Effect of On-Site 12-Step Meetings on Outcomes among Outpatient Clients

Onsite 12 step meetings improve outpatient treatment outcomes:

On-site 12-step enhanced 12-step attendance, especially during treatment, and predicted continuous abstinence for the post-treatment year. Holding 12-step meetings on-site is a low-cost strategy that programs should consider to foster post-treatment remission maintenance.

I'm a little ambivalent about this, only because it would be so easy to have a lame meeting that serves the treatment program rather than the recovering community. It's my experience that this is the case more often than not. A case of the good being the enemy of the best. Easy to do. Doing it is good. But, doing it really well is not easy.

via alcoholreports.blogspot.com

Celebrating drugs

One third of hit songs mention alcohol, drug use:

Primack and his team, who presented their findings at a medical meeting, looked at the top 279 songs on the Billboard charts in 2005. They found that 33 percent made references to alcohol and drug use.

Nearly 80 percent of rap songs mentioned substance use, followed by 37 percent of country music lyrics, 20 percent of R&B/hip-hop and 14 percent of rock songs. Only 9 percent of pop songs referred to drug or alcohol use.

The researchers only included songs that clearly referred to using drug and alcohol. They also named the substances which included alcohol, marijuana, cocaine, prescription drugs, inhalants, hallucinogens, and substances of unknown origin.

"If someone says, 'I had one of those pills,' and you don't really know what that was, we call that non-specific," Primack explained in an interview.

via ccsa.ca

Drug inflation

No mention of heroin or other opiates. My impression is that heroin prices are stable or down. Also, we've seen a downturn in cocaine admissions, continuing increases in heroin and other opiates, and we still see very few meth admissions.

Prices for cocaine and methamphetamine have risen for the fourth quarter in a row, a trend law enforcement officials say indicates supply has dropped.

The price for a pure gram of cocaine increased 47% since October 2006. The price of a pure gram of methamphetamine jumped 84%, says a report out Thursday by the Drug Enforcement Administration.

...

A gram of pure cocaine cost about $137 in September, up from $93 in October 2006, according to a DEA database that analyzes seized illegal drugs. A gram of pure methamphetamine cost $245 in September, up from $133 in October 2006. The DEA uses the database to gauge illegal drug markets. High prices and low purity generally indicate a short supply. Dealers often use filler ingredients to stretch a drug supply.

via dailydose.net

Landmark study on SUD and depression in teens

A breathless press release is hyping the findings in a new study:

The adolescents were randomly assigned to receive either 20 milligrams of fluoxetine daily or a placebo, along with cognitive behavioral therapy (CBT) focused on substance abuse rather than depression.

"The weekly, individual cognitive behavioral therapy helps adolescents improve their decision-making skills as well as their coping, communication, and drug-refusal skills," added Riggs. "It also helps adolescents learn ways to avoid high-risk situations and increase their motivation and involvement in pro-social activities that are incompatible with drug use."

The study found fluoxetine combined with CBT was well-tolerated and had greater efficacy than the placebo with CBT on the Childhood Depression Rating Scale-Revised but not on the Clinical Global Impression Improvement measure of treatment response. Drug use and conduct disorder symptoms decreased significantly in both the fluoxetine and placebo treatment groups but there was no difference between fluoxetine and placebo treatment on either variable. The rate of treatment retention/completion (84 percent) was higher and reduction in drug use similar to that reported for other evidence-based substance treatment modalities in adolescents with less psychopathology.

Then there's this pearl:

The higher than expected rate of treatment response (CGI-I) in the placebo + CBT (67 percent) as well as the fluoxetine + CBT (76 percent) treatment group may indicate that CBT contributed to depression treatment response, despite its focus on substance abuse. Adolescents whose depressions remitted (regardless of medication group assignment) significantly decreased their drug use whereas drug use did not decrease in those whose depressions did not remit.

Ton anyone who is familiar with the literature, it should be no shock that depression would respond to CBT, even if it's substance abuse focused CBT. Further, anyone familiar with the literature would know that depressive symptoms generally improve dramatically in the first 3 to 6 weeks of abstinence, without any treatment for mental illness.

A remarkable conclusion:

"An important clinical implication of these results may be that in the context of cognitive behavior therapy (substance abuse treatment), co-occurring depression may significantly improve or remit without antidepressant pharmacotherapy," said Riggs.

Given that conclusion, why isn't the headline, "CBT very effective for treating depression in youth with SUDs"? Or, "Fluoxetine provides modest benefit for depressed teens with SUDs"?

UPDATE: Other possible headlines: "Substance abuse treatment effective for depression in teens", "Psychiatric treatment unnecessary for most depressed teen substance abusers"

They're all accurate, right? They're all also very different. Does this demonstrate that scholarly journals are used professional advocacy tools? At minimum, it's evidence that they reflect the assumptions and biases of that discipline.

Virtual drug dens!

A new spin on cue extinction therapy.

Insomnia

More support for non-pharmacological treatment of insomnia--a common problem among recovering addicts:

For people with chronic insomnia, studies show that simple behavioral and psychological treatments work just as well, and sometimes better, than popular medications, according to a report in The Journal of Family Practice.

The medical journal Sleep last year reported on five high-quality trials that showed cognitive behavioral therapy helped people suffering from insomnia fall asleep sooner and stay asleep longer. Another American Journal of Psychiatry analysis of 21 studies showed that behavioral treatment helped people fall asleep nearly nine minutes sooner than sleep drugs. In other measures, sleep therapy worked just as well as drugs, but without any side effects.

The behavioral strategies for better sleep are deceptively simple, and that’s one reason why many people don’t believe they can make a difference. One of the most effective methods is stimulus control. This means not watching television, eating or reading in bed. Don’t go to bed until you are sleepy. Get up at the same time every day, and don’t nap during the day. If you are unable to sleep, get out of bed after 15 minutes and do something relaxing, but avoid stimulating activity and thoughts.

So-called sleep hygiene is also part of sleep therapy. This includes regular exercise, adding light-proof blinds to your bedroom to keep it dark and making sure the bed and room temperatures are comfortable. Eat regular meals, don’t go to bed hungry and limit beverages, particularly alcohol and caffeinated drinks, around bedtime.

Finally, don’t try too hard to fall asleep, and turn the clock around so you can’t see it. Watching time pass is one of the worst things to do when you’re trying to fall asleep.

Pot, Tobacco and Youth

A new study challenges some assumptions about marijuana use by adolescents:

A study of more than 5,000 youngsters in Switzerland has found those who smoked marijuana do as well or better in some areas as those who don't, researchers said Monday.

But the same was not true for those who used both tobacco and marijuana, who tended to be heavier users of the drug, said the report from Dr. J.C. Suris and colleagues at the University of Lausanne.

The study did not confirm the hypothesis that those who abstained from marijuana and tobacco functioned better overall, the authors said.

In fact, those who used only marijuana were "more socially driven ... significantly more likely to practice sports and they have a better relationship with their peers" than abstainers, it said.

"Moreover, even though they are more likely to skip class, they have the same level of good grades; and although they have a worse relationship with their parents, they are not more likely to be depressed" than abstainers, it added.

It did not explain the reasons behind the apparent effect.

The researchers also found that those who smoked tobacco were more likely to be heavy users and that those who started before the age of 15 were more likely to be heavy users and misuse alcohol.

This has been trumpeted as proof that marijuana is harmless (here and here). Surely, its harm is hyped. But, this is one study, it appears to be something of an outlier, and skipping class and worse relationships with parents are not insignificant (I'm not suggesting that corelation is causation.). It would be interesting to see this done in a longitudinal study and to see if the findings hold. Of course it would also be good to see the study replicated.

Arch Pediatr Adolesc Med. 2007;161(11):1042-1047.

Recovery is everywhere

From the New York Times:

As he coaches one of the highest-ranked high school soccer teams in the country, Martin Jacobson also battles hepatitis C, a disease he contracted in an earlier life as a drug addict.

Mass. plans new heroin overdose program

It looks like Massachusetts is moving ahead with their narcan distribution plan. (Previous post here.)

Massachusetts officials next month will begin distributing kits to heroin addicts that include medication to treat overdoses.

Advocates say the kits will help treat overdoses quickly, safely and without fear of addiction, and will be beneficial in a state where more people die from heroin than firearms.

...

"It's a remarkably safe drug," said Dr. Peter Moyer, medical director for Boston's fire, police, and emergency medical services. "I've used gallons of it in my life to treat patients."

Heroin and other opiates killed 544 people in Massachusetts in 2005, more than double the number killed by firearms.

Strong demand and low prices make heroin a popular street drug in New England. At $5 or $6 for a small bag, heroin can cost less than a six-pack of beer.

"It's the perfect storm in all the wrong directions. We talk about availability, price, and potency of the drug," said Kevin Norton, president of CAB Health & Recovery Services, which will work with the state to provide Narcan in cities and towns on the North Shore.

State Public Health Commissioner John Auerbach, who started the Boston kit distribution program when he worked for the city, emphasized that treatment is still the state's priority.

What does it mean to say that treatment is still the state's priority? Do they have adequate treatment on demand?

Why You Should Be Skeptical About "Scientific" Studies

Bob Sutton offers a graphical explanation of why you should be skeptical of scientific studies:

Philly Needle-exchange angers neighbors

Another community voicing concern about a needle exchange.

This case might be interesting to watch. Philadelphia is in the process of transforming it's mental health and addiction treatment systems into a comprehensive, recovery-oriented system of care. If any community is capable of creating a recovery-oriented needle exchange, it might be Philly.

Passive smoking rates drop by 95% among hospitality workers

Early returns from an indoor smoking ban in England:

The study for charity Cancer UK and carried out by the Tobacco Control Collaborating Centre in Warwick found non-smoking hospitality workers had four times less cotinine - a byproduct of nicotine and an indicator of tobacco smoke exposure - in their saliva in August than they had in June.

They calculated that, on average, employees' exposure was the equivalent to smoking 190 cigarettes a year before the legislation, and that this had fallen to the equivalent of around 44 cigarettes since.

via dailydose.net

Opiate addiction in England

Two stories about opiate addiction in England. One that challenges the efficacy of methadone and another that suggests drug-free recovery is not possible.

via dailydose.net

Comment on "A rare head to head"

This comment from a friend seemed worth posting, just to make sure everyone sees it:

An important addition seems important here. Chantix + ongoing skill building and social support, is the combination that is getting results at 52 weeks. At 6 months, without any social support, the return to smoking rate remains high. I was just in the audience as Dr. Gonzales presented an unpublished study that showed a pattern of slips and relapses for up to 6 months, then stability.

The ongoing studies continue to show us that recovery from tobacco use is a process, not typically a "cessation" event. I think the time is ripe for addiction professionals to enter the tobacco treatment arena. We have much to offer.

Wendy Croze BA, CAC-R, TTS

Insula-palooza

More on the insula and addiction:

Abstract: We have investigated shape deformation of the insula to get a viewpoint of how chronic alcohol consumption affects the perisylvian region and compared the deformity pattern between the left and right hemisphere. A landmark-based structural and surface shape analysis of the insula was performed in 20 patients with alcohol dependence and 20 controls matched for age. The shape analysis revealed that the left and right insula follow distinct shape deformation patterns, which resulted in the reduction of left-right asymmetry. The shape deformity was most prominent in the central part of both insula. Our findings indicate that the right and left hemisphere are both affected but shows distinct patterns of deformation in alcohol dependence.

More brain science

Yesterday, I posted about recent findings related to the insular cortex and stimulants. I should have mentioned that this region was identified last year in a study of stroke patients who forgot to smoke.

Substance-Induced Versus Independent Depressions

A new study on substance-induced major depressive episodes (MDE) reaches a bold conclusion:

This study corroborates a high rate of substance-induced MDEs among alcoholics, with these disorders explaining about half of the lifetime depressive episodes.

Also worth noting, substance induced depressive episodes were no less severe:

...symptoms during the worst depressive episode were quite similar across [subjects with substance induced MDEs] and [subjects with independent MDEs].

More addiction brain research

Care to turn off your insular cortex?

Tests on amphetamine-addicted laboratory rats showed that when the insular cortex was deactivated by injecting a drug that halted brain cell activity, the rats showed no signs of addiction.

When the insular cortex was reactivated, the rats again showed signs of craving amphetamines, according to the research to be published in Friday's edition of the journal Science.

Cutbacks hit drug courts hard

Bad news for Michigan drug courts.

Parity

Health Affairs has a pretty comprehensive overview of the case for parity. Well worth the time it takes to read.

Emotions Run Amok in Sleep-Deprived Brains

More (probably unneeded) evidence for the wisdom of H.A.L.T.

A rare head to head

Chantix vs. Zyban vs. placebo:

Results showed that 22% of participants who used varenicline were able to remain abstinent for the full 52 weeks of the study, a rate two-and-a-half times that of the placebo.

S.F. injection center idea draws, support and doubt

San Francisco mulls Vancouver's experience.

Highlight:

"It's really been studied to death - it's time to move on," Kerr said. "It's obvious this is something that works."

I suppose it depends on your definition of "works." More here.

Too much cannabis 'worsens pain'

More isn't always better:

The pain-relieving qualities of cannabis have long been hailed, and several countries have made it available for medicinal purposes.

But quantity is key, according to the study in the journal Anesthesiology.

...those who had smoked the moderate dose said their pain was much better, while those who consumed high doses said it had got worse.

They did, however, feel "higher" than counterparts who had taken moderate doses.

Neurobiology of alcohol craving

I've seen several MRI studies of cocaine cravings, but I don't remember seeing the same for alcohol:

Aims: This study's purpose was to identify the neural substrates and mechanisms responsible for craving among subjects with alcohol use disorders (AUDs) using functional magnetic resonance imaging (fMRI). Methods: Alcohol abusers with AUD (n = 9) and demographically similar non-abusers (n = 9) participated in this study. After given 5 cc of alcohol, subjects were exposed to different types of stimuli [i.e. alcohol, non-alcoholic beverage, and visual control pictures and one rest (cross-hair)]. Craving levels were rated through self-report on a Likert scale immediately after the presentation of visual cues. Results: Brain activations in the fusiform gyri, temporal gyri, parahipocampal gyrus, uncus, frontal gyri, and precuneus were correlated with the level of craving among subjects with AUD in response to alcohol cues. Conclusions: In conclusion, specific brain regions were identified that are associated with craving among subjects with AUD.

Needle exchange an unmitigated disaster

The Victoria Times Colonist recently published a description of what it's like to live near a needle exchange. Not to sound too cocky, but HR programs like this could do themselves a favor by reading and thinking about our position paper on HR. (Value number 5, in particular.)

Child killings challenge the drug war

Nolan Finley takes on the drug war:

You want to know why kids are being killed in Detroit? Because drug dealing is a $100 billion enterprise in the United States. All of that money moves through the criminal underground, where it is untaxed, unregulated and untraceable.

The only way to stop the drug trade from consuming our children and our communities is to take the profit out of selling dope.

For more than 30 years, we've tried to do that by kicking in doors, rounding up street corner dealers, cutting off international supply lines and filling our prisons. And it hasn't worked.

It will never work. Those determined to destroy themselves with drugs will find a way to do so, just as those who prefer to ruin their lives with alcohol or gambling, vices the government decided that, if we can't beat 'em, we might as well tax 'em.

So let's get the drugs off the street and into the pharmacies where they belong. Pick a variety of narcotics, from marijuana to heroin, and sell them in measured doses over-the-counter, like packaged liquor.

Move the drug money from the alleys to Wall Street. Let the pharmaceutical companies produce, sell and pay taxes on narcotics.

Perhaps we'll have more users when drugs are no longer illegal. But legalizing drugs will allow rehabilitation resources to be focused on those who truly have a problem, and create more funding for anti-drug education.

A drug-free America is an impossible dream. Our stubborn determination to press this lost cause is killing people.

If it were just the dope dealers who were dying, I'd say have at it. That's addition by subtraction.

But in Detroit we've seen the collateral damage of this misguided war.

When babies die in their beds, we have to start challenging the premises of the drug war, and asking whether the fight is worth the cost.

I've addressed these arguments before. (Imagine the power of the pharmaceutical, tobacco and alcohol industries being invested in legal opiates, cocaine and marijuana. Imagine what new drugs and methods of administration could be developed in corporate R & D departments.)

Why does this have to be a choice between the war on drugs and legalization? It doesn't.

Narcan handouts

The Boston Herald ran an article on a local Narcan handout program. Highlights:

Advertising with the glib phrase “Got Narcan? Need a refill?” plastered on the side of its needle exchange vans, the Boston Public Health Commission is stuffing the pockets of Hub junkies with the powerful prescription drug in hopes of countering heroin overdoses.

But front-line ambulance workers said giving addicts a powerful overdose remedy is a flat-out “stupid” practice that encourages uninhibited drug use and could even endanger their lives.

“The solution is for a health care professional to administer the drug, then offer them detox. These days you don’t know if the heroin is laced with something that can interact with it,” said Matt Carty, head of the Boston Police Patrolman’s Union/EMS Division. “It’s stupid, and you can quote me on that.”

The Public Health Commission, which oversees the emergency medical service, reports that since it began distributing Narcan a year ago, the drug has saved 50 addicts from overdoses.

Dr. Peter Moyer, the commission’s medical director, said the bottom line is that Narcan saves lives. It also keeps addicts returning to the city for services and counseling so that one day perhaps the addict will want to get off drugs, Moyer added.

“There’s really no downside to its use,” Moyer said. “They (addicts) do get training.”

What makes me nuts is not so much that they are handing our Narcan. It's that it's done in the context of no access to meaningful to treatment or recovery support services.

Sorting out protective and risk factors

Here's a study highlights how little we know about protective and risk factors:

The risky drinkers reported only slightly higher prevalence of experiencing child abuse or witnessing domestic violence compared to their non-risky drinking counterparts (see Table 1). However, those recruits who reported first drinking around 13 years were 5.5 times more likely to engage in riskier drinking behavior than recruits who reported first drinking after age 13. Other significant and anticipated predictors of young adult drinking were smoking, having a rural or small town background, having grown up with someone who was a problem drinker or having grown up with someone who suffered from mental illness. Some unexpected correlates of risky drinking were achieving a higher educational level, having more close family members or friends, and being raised by two parents.

...Young et al. (2006) provide support for the importance of age of onset to young adult drinking habits; however, they did not find adverse childhood experiences to be equally strong predictors of young adult drinking. Interestingly Young et al. (2006) noted that they did not expect to find that risky drinkers had a number of experiences that one might expect to be protective, such as, a higher number of close family and friends, a higher level of education, along with being slightly more likely to be raised by two parents. Young et al’s (2006) research shows that multiple and interactive factors, whether prototypically protective or detrimental, can be associated with harmful drinking behavior. The presence of protective childhood experiences does not guarantee a young adult life without substance abuse problems.

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A tale of two cities...

Two recent articles about harm reduction plans in two cities.

I have lots of thoughts, but here's one quick one about the San Francisco story. Placing an injection center in the area with the highest OD rates seems obvious. But, would such a program (As opposed to a recovery oriented program.) further institutionalize addiction in this struggling community? Also, I've heard that the Tenderloin district is becoming gentrified. What might this do to plans for an injection center? What does that say about treatment of socio-economic classes?

Rethinking confrontation

I posted on this when it came out, but Bill White and Bill Miller recently published an article on confrontation that was just made available on the Counselor Magazine website. It makes a terrific point on confrontation as a therapeutic goal in contrast to confrontation as a therapeutic style:

In its etymology, the word “confront” literally means “to come face to face.” In this sense, confronting is a therapeutic goal rather than a counseling style: to help clients come face to face with their present situation; reflect on it; and decide what to do about it. Once confronting is understood as a goal, then the question becomes how best to achieve it. Getting in a person’s face is rarely the best way to help them open up to new perspectives. There is, as Hazelden observed in its 1985 recanting of aggressive confrontation, “a better way.” People are most able and likely to re-evaluate reality within safe, empathic, supportive and nonjudgmental interpersonal relationships that do not necessitate defensiveness.

One unrelated thought...what is up with the photos that Counselor chooses? Is it just me, or do they make addicts look like dangerous, crazy and volatile psychopaths?

"war on drugs"

The first time the New York Times used the phrase "war on drugs":

June 14, 1919

Health Commissioner Copeland Defends His War On Drugs
According to a statement given out yesterday by the Bureau of Narcotic Research, representing in its membership a number of philanthropists and medical men interested in the drug problem…the question that is interesting the doctors is how far the municipal and State authorities are seeking to interfere with the private practitioner’s efforts in curing drug addicts. Any amendments to the sanitary code as have been proposed that will aim to treat as a single class the thousands of persons addicted to the use of narcotics will be vigorously resisted by the doctors, says the bureau’s statement.

It also states that, according to figures compiled by the Police Department, there are at present some 250,000 addicts in New York. Of this number only about 15 percent are of the criminal or underworld classes, it says, and 212,500 of the total are making every effort to be cured.

via Mental Floss

Amsterdam's Magic Mushroom Tourists May Trip on Sales Crackdown

Drug tourists may be losing a destination:

Paul arrived in Amsterdam looking forward to a weekend with his friends. Instead, the 24-year-old Australian stayed holed up in his hotel room, too frightened to walk the streets after taking magic mushrooms.

"We had to lock ourselves up in case we would do something crazy,'' said Paul, who asked that his last name not be used because he didn't want acquaintances to know about his drug use. "There is no way this should be legal.''

In Amsterdam, where the fungi are sold in so-called smart shops, local officials agree. The city council last month approved a three-day waiting period to cut down on tourist use. The national government is considering an outright ban after a French teenager leapt to her death in March. Health Minister Ab Klink will release a statement on the hallucinogens this week.

Technorati Tags: drugs, policy, europe, legalization, hallucinogens

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Helping other alcoholics in alcoholics anonymous and drinking outcomes

This isn't a new article, but seemed worth sharing. Researchers demonstrate what mutual aid groups have known for decades. Helping other alcoholics helps the helper stay sober.

OBJECTIVE: Although Alcoholics Anonymous (AA) is the largest mutual-help organization for alcoholics in the world, its specific mechanisms that mobilize and sustain behavior change are poorly understood. The purpose of this study is to examine prospectively the relationship between helping other alcoholics and relapse in the year following treatment for alcohol use disorders. METHOD: Data were derived from Project MATCH, a longitudinal prospective investigation of the efficacy of three behavioral treatments for alcohol abuse and dependence. Kaplan-Meier survival estimates were used to calculate probabilities of time to alcohol relapse. To identify the unique value of helping other alcoholics when controlling for the number of AA meetings attended, proportional hazards regressions were conducted to determine whether the likelihood of relapse was lower for those who were helping other alcoholics. RESULTS: There were no demographic differences that distinguished participants in regard to involvement in helping other alcoholics, with the exception of age; those who were helping other alcoholics were, on average, 3 years older than those who were not helping alcoholics. Those who were helping were significantly less likely to relapse in the year following treatment, independent of the number of AA meetings attended. CONCLUSIONS: These findings provide compelling evidence that recovering alcoholics who help other alcoholics maintain long-term sobriety following formal treatment are themselves better able to maintain their own sobriety. Clinicians who treat persons with substance abuse disorders should encourage their clients to help other recovering alcoholics to stay sober.

It would be interesting to look at two more things:

• If these finding hold up in other mutual aid groups. I suspect they would.
• We know that mutual aid group involvement is a better predictor of recovery than attendance. 12 step work is frequently identified as an indicator of involvement. It would be interesting to see if the benefits of helping are are different or more powerful than other forms of mutual aid group involvement.
  

Technorati tags: recovery, alcoholism, aa, mutual_aid, research, addiction

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Europe: Curing, not punishing, addicts

This Op-Ed is a little simplistic, but does a decent job illuminating the difference in approaches. However, I find the headline to be the most striking thing about it. The problem I have with drug policy in some European countries isn't their lack of enforcement, it's the overemphasis on maintenance and harm reduction. Curing, as the headline suggests, does not appear to be a goal at all.

via dailydose.net

Technorati Tags: policy, harm_reduction, drugs, america, europe, addiction, drugs

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Five Myths About Crack

A Washington Post Op-Ed contributor offers some guidance to the supreme court in the form of 5 myths about crack:

1. Crack is different than cocaine.
2. Crack is instantly and inevitably addicting.
3. The "plague" of crack use spread quickly into all sectors of society.
4. Crack is the direct cause of violent crime.
5. Harsh sentences for crack are necessary to deter "serious" and "major traffickers."

Technorati Tags: cocaine, crack, policy, criminalization, addiction

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Seizure Drug May Treat Alcoholism

Topiramate has been used to treat alcoholism for a little while now and was featured in the HBO Addiction series. This story has been very widely reported over the last few days. It may become a useful tool for a small number of alcoholics, but I find the results reported in this article pretty underwhelming:

Compared with placebo treatment, treatment with Topamax was associated with an 8 percent greater reduction in the percentage of heavy drinking days during the trial, the researchers reported.

Researcher Bankole Johnson, MD, tells WebMD that alcoholics in the trial who took Topamax went from the equivalent of drinking a bottle and a half of wine a day to about 3 1/2 glasses of wine.

"I think that is a big difference," he says. "Most people can manage that amount of alcohol without getting into too much trouble."

The researchers reported that Topamax users had a greater rate of achieving 28 or more days of continuous nonheavy drinking during the study and 28 days of continuous abstinence.

The manufacturer has also been accused of promoting off-label use:

But in a letter to the FDA, the consumer interest group Public Citizen accused the company of illegally promoting use of the drug for this purpose.

While doctors can legally prescribe FDA-approved drugs for nonapproved conditions, it is illegal for the companies that market the drugs to promote these so-called "off label" uses.

The Public Citizen complaint involved a question-and-answer sheet distributed to the media before publication of the study, which specifically discussed the drug's potential "off label" use for alcohol dependence.

Kara Russell of Ortho-McNeill tells WebMD that the company knew nothing about the question-and-answer sheet until the Public Citizen letter became public."

Ortho-McNeil Neurologics does not support any reference to off label use of its products and only promotes the use of Topamax in the approved indication of migraine and epilepsy treatment," Russell says.

I'm not surprised. I've wondered what arrangement led to the prominent placement of topiramate in the HBO series. It was practically an infomercial and led the lay people I know to grossly overestimate the effectiveness of the drug.




Technorati Tags: topiramate, addiction, alcoholism, treatment, research, medication

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More on the new Canadian drug plan

65% for prevention and treatment (including culturally specific treatment) doesn't exactly sound Draconian:

The Conservative government's new $63.8-million, two-year drug strategy could be worse, but it could be better.Fully half the money will go toward beefing up treatment for addicts. Since health and social services are mainly a provincial responsibility, however, that money will go mainly to development of national benchmarking - so that evaluations can be consistent across the country - and extra programs for aboriginals. The main burden of helping addicts remains with the provinces.Another $10 million will go to prevention - ad campaigns and brochures to remind people, especially young people, how damaging addiction is. "Drugs are dangerous and destructive," Prime Minister Stephen Harper said, unveiling the plan. "If drugs do get hold of you, there will be help to get you off them."

Based on American experience, mandatory minimum sentences don't seem like a wise move, but why not start lobbying and negotiating instead of calling them idiots.


Technorati Tags: canada, addiction, treatment, prevention, policy

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